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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
November 02, 2017 - The least satisfied customers are those whose
problems remain unsolved. … It can also
mean providing solutions or making amends for problems that the patient created. … Solutions to problems need to be timely and responsive to the
person’s need. … In health care, certain problems are highly predictable. … • Train and empower frontline employees to resolve problems and
give them the authority to fix problems
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
June 01, 2021 - Identifying Targets
4
Opportunities for Improvement
Mistakes
Near Misses
Defects
Errors
Problems … 12
13
The antibiotic stewardship team
Physician lead
Pharmacist lead
Nurse lead
Prioritize top problems … system opportunities to prevent them from occurring again
Identifying Targets
14
Technical Problems … Identifying Targets
15
Adaptive Problems
Adaptive solutions require a change in attitudes, beliefs, … Using the Four Moments of Antibiotic Decision Making Form may help identify problems.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
January 01, 2005 - Rapidly identify and understand problems with the use of medical
devices,
2. … There are numerous reasons why user facilities may
underreport device problems. … This person sometimes does not want problems reported under his or
her “watch.” … Thus, usage problems may go unreported. … more they learn about
problems they did not know existed.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
June 04, 2008 - • Provide a “laboratory” for research into understanding problems with these medical products
as … They send reports about problems with the use of medical devices through the secure
online system into … The
very large percentage of reported problems falling into the “potential for harm” category speaks … However, rare or unusual
problems often go unreported.
Therefore, Dr. … LabNet is designed to collect information about devices, whether problems (e.g., with
point-of-care
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
January 01, 2020 - 12
months
Problems
several
times
in the
past 12
months
Problems
monthly
Problems
weekly … Problems
several
times
in the
past 12
months
Problems
monthly
Problems
weekly
Problems … 12
months
Problems
several
times
in the
past 12
months
Problems
monthly
Problems
weekly … 12
months
Problems
several
times
in the
past 12
months
Problems
monthly
Problems
weekly … in the past 12 months” to “Problems daily”:
• No problems in the past 12 months,
• Problems once or
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english-2023.docx
January 01, 2023 - exchanging accurate, complete, and timely information with:
Problems daily
Problems
weekly … Problems
monthly
Problems
several times
in the past 12 months
Problems
once or
twice … in the past 12 months
No
problems
in the
past 12
months
Does Not
Apply or Don’t
Know … We have problems with workflow in this office
1
2
3
4
5
9
13. … Providers and staff talk openly about office problems
1
2
3
4
5
9
9.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
June 01, 2023 - patients’ experiences about diagnostic errors is even more limited. 18 As one paper about diagnostic problems … literature. 21,22
Patients and families offer a unique source for understanding a variety of diagnostic problems … adverse events on the health and well-being of patients. 26
Understanding the impact of diagnostic problems … since remediation efforts in response to patient feedback will induce more subsequent reporting of problems … brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors,” “diagnostic problems
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre/ready.html
January 01, 2024 - Readiness Assessment
Investing in TeamSTEPPS typically requires one or more identifiable problems … If these problems are directly linked to teamwork and communication failures, they may help show the … extent of the problems the TeamSTEPPS implementation will seek to overcome.
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www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14notes.html
June 01, 2014 - When data problems were found, medical offices were contacted and asked to make corrections and resubmit … in the past 12 months" to "Problems daily" (No problems in the past 12 months, Problems Once or twice … in the past 12 months, Problems several times in the past 12 months, Problems monthly, Problems weekly … , Problems daily). … months, problems once or twice in the past 12 months, and problems several times in the past 12 months
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
July 18, 2008 - Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising … Teamwork Tools and Strategies
Understanding Quality and Safety Problems in the
Ambulatory Environment … The
authors comment that no “silver bullet” can solve such complex problems. … Problems with medications: Adverse drug events (ADEs). … wrong dose,
wrong person, and wrong route problems that may result in ADEs.
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www.ahrq.gov/hai/cusp/toolkit/shadowing.html
December 01, 2012 - The shadower will observe oral and written communication practices and problems and the effect they have … Use this document to identify problems observed in patient care areas within the practice setting of … Discuss with the provider you shadowed what you believe may reduce communication errors and teamwork problems … Prepare a draft of the problems identified and your proposed solutions. … Were patient problems identified quickly?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving.pptx
May 01, 2017 - Most problems are identified by staff or are observed by supervisors. … The daily huddle gives you a place and time every day to speak up about problems observed by team members … Reduce the number of recurring problems
How will you know that a change is an improvement? … Fewer problems of the same kind flagged in huddle and observed at work
What can you change to make an … Management
• Outcomes over time
• Checklist compliance
• Problem log
Escalation
• Sentinel events
• Problems
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-fac-notes.html
June 01, 2017 - At the center of the system is daily work, including huddles, where problems are identified, anticipated … Huddles give you an opportunity to recognize problems from yesterday’s work, anticipate problems for … Identify someone to write down problems from yesterday and concerns for upcoming cases. … tests, you may start to recognize some additional problems. … It may take time to surface problems and to put into place resources and projects to solve them.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/huddles/daily-huddles-facnotes.docx
May 01, 2017 - At the center of the system is daily work, including huddles, where problems are identified, anticipated … Huddles give you an opportunity to recognize problems from yesterday’s work, anticipate problems for … This will help you identify problems that may surface in trying to do huddles on consecutive days. … tests, you may start to recognize some additional problems. … It may take time to surface problems and to put into place resources and projects to solve them.
-
www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
December 01, 2012 - Purpose of tool: This tool provides a structured approach to help physicians and nurses identify the problems … that occurred during the night and potential problems that may occur during the clinical day. … Are there any patients having problems on the unit?
III. … To Followup
Action Taken
Patient scheduling
Equipment availability or problems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_apptaide.pdf
December 01, 2017 - What problems should I look for, and what do I need to do if I have these problems? … (Use “The Problems I
Need to Look For” page to help you remember who to contact when you have these … problems.)
5. … What problems should I look for? Who should I contact if the patient has these problems?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
January 01, 2004 - This method is for the
evaluation of usability problems in medical devices. … Figure 3 summarizes the severity of the problems found in Pump 1 and Pump
2. … For Pump 2, there was 1
catastrophic, 26 major, 26 minor, and zero cosmetic usability problems. … Finding usability problems through
heuristic evaluation. … Severity ratings of usability problems for the two 1-channel infusion pumps
Figure 4.
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www.ahrq.gov/prevention/chronic-care/decision/research-centers/index.html
October 01, 2018 - Each center is conducting three research projects seeking solutions to the problems of underuse, overuse … difficult in routine primary care because of time constraints, conflicting priorities, communication problems … the AHRQ Research Centers for Excellence in Clinical Preventive Services are finding solutions to the problems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
May 01, 2017 - The shadower will observe oral and written communication practices and problems and the effect they have … Use this document to identify problems observed in patient care areas within the practice setting of … Review your list of observed communication and teamwork problems. … Prepare a draft of the problems identified and your proposed solutions. … Were patient problems identified quickly?
-
www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/premortem-assessment.html
October 01, 2024 - Prevention The purpose of the CUSP Premortem Tool is to help the CUSP team anticipate and mitigate potential problems … 394 KB) The CUSP Premortem Tool walks teams through the Premortem process to anticipate and mitigate problems